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Overview of the New IDAPA Rules for Provider Owned or Controlled Residential Settings May 6, 2016 Note: This meeting will be recorded. The recording will be posted to the HCBS webpage 2 Home and Community Based Settings: Provider Training

Webinar Topics for Today 3 Brief history of the new HCBS rules Intent of the new HCBS Rules Today’s overview will focus on the new IDAPA rules that apply to provider-owned or controlled residential settings where HCBS are delivered This includes Residential Assisted Living Facilities (RALFs) and Certified Family Homes (CFHs) Compliance timeline review Upcoming additional training opportunities

Background 4 The Centers for Medicare and Medicaid Services (CMS) published new regulations in 2014 that implemented new requirements for state Medicaid HCBS programs. To ensure that individuals receiving long-term services and supports through home and community based service (HCBS) programs under the 1915(c), 1915(i) and 1915(k) Medicaid authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate To enhance the quality of HCBS and provide protections to participants

Background 5 CMS required states to develop Statewide Transition Plans that describe the state’s plan to ensure full compliance with the regulations no later than March Idaho submitted its Statewide Transition Plan to CMS in October 2015 – it is still pending approval. This plan describes the steps that Idaho Medicaid is taking to move into full compliance. We recently completed one step of that Transition Plan with the promulgation of new IDAPA rules.

Intent of the IDAPA Rules 6 To have sound regulatory support for implementing the new requirements To have HCBS rules specific to Idaho and its programs

IDAPA This first subsection of the new set of rules indicates Idaho’s HCBS programs are: Children’s Developmental Disability Services Adult Developmental Disability Services Consumer-Directed Services Aged and Disabled Waiver Services Personal Care Services

IDAPA This subsection specifies that the HCBS rules do not supersede the decision-making authority that has been legally assigned to another individual or entity. These entities include: Payee Court-imposed restrictions related to probation or parole Court-imposed restrictions when committed to the Director of Health and Welfare Legal Guardians (including parents of minor children, unless the child has another legally assigned decision-making authority)

IDAPA continued 9 This means that the HCBS requirements do not “trump” or replace a guardian’s decision-making role for a participant. This does not mean that a guardian may decide that a setting requirement does not need to be met for a participant just based on the guardian’s personal values or beliefs.

Examples of Decision-Making Authority 10 Example: A guardian does not want an individual to participate in the community activities offered by the Adult Day Health where she receives services. However, there are no identified health or safety risks to the participant – it is just the personal preference of the guardian. Therefore, the provider cannot prohibit the participant from participating in those community activities.

Examples of Decision-Making Authority 11 Another example: A guardian wants a CFH provider to limit an individual from going out into the community without supervision. The guardian is concerned because the individual has historically exhibited aggressive behaviors, and he fears that the individual could injure someone or be injured herself. The individual, guardian, plan developer and CFH work together to develop a risk mitigation strategy that is documented in the service plan.

IDAPA This subsection defines HCBS settings as all locations where people receiving HCBS live or receive their services. HCBS settings are NOT: Nursing facilities Institutions for mental diseases Intermediate Care Facilities for persons with Intellectual Disabilities Hospitals

IDAPA continued 13 HCBS settings are NOT settings that have qualities of an institution. Qualities of an institution include: Located in a building that provides inpatient institutional care Located on the grounds of, or adjacent to, a state or federally operated inpatient facility Has the effect of isolating participants from the broader community This means that HCBS cannot be delivered in a setting that is an institution or has the qualities of an institution – namely, isolating the participants that receive services or reside there.

IDAPA This subsection describes the qualities that all HCBS settings must have. Settings must: Be integrated in and support full access to the greater community Be selected by the participant, based on their needs and preferences, and include consideration of the participant’s safety and the safety of those around the participant. Ensure that participants’ rights to privacy, dignity, respect, and freedom from coercion and unauthorized restraint are honored

IDAPA continued 15 Settings must also: Optimize an individual’s initiative, autonomy, and independence. This means that individuals have opportunities to make choices about how they spend their time in a setting, in the context of the service being offered there. Promote opportunities for participant choice regarding the service and supports provided in the setting. This means that participants have opportunities to make choices and provide feedback about the services they receive in that setting.

IDAPA continued 16 If a setting quality poses a health or safety risk to a participant or those around a participant, then the participant, guardian, and person-centered planning team may discuss the implementation of risk mitigation strategies during the person centered planning process.

IDAPA continued 17 This subsection also specifies that providers of services furnished in a participant’s own home can’t limit these setting qualities without risk mitigation goals and strategies that are documented in the person-centered plan. For example, if a person receives Personal Care Services or Residential Habilitation – Supported Living in their own home, the agency would have to document a risk mitigation goal and strategy based on the participant’s needs if a setting quality poses a health or safety risk.

Risk Mitigation Goals and Strategies 18 Remember, risk mitigation goals and strategies must be implemented when one or more of the setting qualities poses a health or safety risk to the participant or those around the participant. They must be documented in the person-centered plan. Rule does not outline how risk mitigation goals and strategies are implemented or documented: these processes will be program-specific. Additional information on these processes will be available soon through each program.

IDAPA Subsection 314 includes the additional setting qualities that RALFs and CFHs must have. The intention of these rules is to ensure that people receiving HCBS can enjoy the same rights and freedoms in their own homes that all community members have.

IDAPA In addition to the qualities just described, RALFs and CFHs must make sure there is a written occupancy agreement in place for each resident. The agreement must document protections and eviction/discharge processes comparable to those afforded under landlord tenant laws.

IDAPA Participants living in RALFs and CFHs have the right to privacy in their living unit. This includes: The right to have a lock on their door. Appropriate staff can still have a key to the door in case of an emergency. A choice of roommate. This means that participants should be able to meet their potential roommate(s) before move-in. The provider should have a mechanism in place for participants to request a change of roommate. No one wants to be forced to live with a complete stranger or someone they’re uncomfortable with!

IDAPA Participants living in RALFs and CFHs are free to furnish and decorate their sleeping or living units. Providers can impose reasonable limitations if they are comparable to limitations anyone in the community might encounter – for example, many landlords don’t allow tenants to change wall paint or have a water bed. These types of limits must be in the written occupancy agreement. This doesn’t mean that providers have to pay for participants’ decorations, it means that participants should have the opportunity to personalize their space so that it looks and feels like their home.

IDAPA Participants living in RALFs and CFHs have the freedom and support they need to control their own schedules and activities. This means that participants have meaningful opportunities to make choices about their day-to-day activities. This can include asking for participant feedback in selecting community activities, offering choices in menu preparation and food options, etc.

IDAPA Participants living in RALFs and CFHs must have access to food at any time. This does not mean that the provider must pay for meals to be available 24-hours a day. Some examples of ways that providers can meet this: Allowing participants to have a small refrigerator in their room Having individual cupboards in the kitchen where a participant can store their own snacks and food items Having a variety of snacks and food items available in between mealtimes

IDAPA Participants living in RALFs and CFHs are able to have visitors of their choosing at any time. This does not mean that providers are prohibited from locking their doors. It also does not mean that residents can be disruptive to other residents of the home by having visitors. This does mean that providers have to allow residents to have visitors. Some examples of ways to meet this include: Having a guest sign-in/sign-out book Locking the front door at a certain time, but requiring that visitors ring the doorbell if it is after hours. Having a space where participants can entertain guests without disturbing roommates or other residents.

IDAPA If one of the residential setting requirements under Subsection 314 poses a health or safety risk to the participant, or those around the participant, an exception can be made for that setting quality. All exceptions must be submitted to the Department or its designee for review and approval. Exceptions for these qualities require that some specific elements be documented in the individual’s person centered plan.

IDAPA Exceptions must include the following in the service plan: The specific assessed need related to the exception Positive interventions and supports used prior to the exception Any less intrusive methods of meeting the participant’s need that were tried but didn’t work A detailed description of the exception Regular collection of data to identify how the exception is working An established time limit for reviewing if the exception is still needed The participant and/or their decision-making authority must agree to the exception An assurance that the exception will not cause harm to the individual

IDAPA The process for submitting exception requests to the Department or its designee for review and approval will be program-specific. Additional information and training on this process will be available soon.

Risk Mitigation vs. Exceptions 29 What is the difference? A risk mitigation strategy is necessary if the qualities described in section 313 present a health or safety risk: The service plan must identify goals with strategies to mitigate the risk. It must include the methods or activities used to minimize risk to the participant. Community access and integration Choice of supports Opportunities to make choices Privacy Freedom from coercion and restraint

Risk Mitigation vs. Exceptions 30 An exception can be made to the residential setting qualities in 314 if an assessed need clearly demonstrates that an adjustment is necessary. Exceptions require additional documentation and must be approved by the Department. Ability to have visitors Locks on entrance and/or bedroom and bathroom doors Freedom to choose furniture/decorations Choice of roommate Freedom and support to make choices about daily life Access to food

Risk Mitigation vs. Exceptions 31 It is important to note that a person receiving residential services may have both risk mitigation strategies and exceptions in place, depending on their specific needs. Risk mitigation and exceptions ensure a participant has the support needed to successfully be part of their community. Remember: We will have additional program-specific guidance to help you understand when and how risk mitigation strategies and exceptions can be made.

IDAPA Subsections are specific to the person-centered service planning process and the person-centered service plan. Program-specific information and training on person-centered planning will be available in the coming months.

IDAPA This subsection indicates that all providers must complete a Department-approved self-assessment. This self-assessment will be available from the Department in August 2016 It will help you determine if you are in compliance with the setting requirements It will also help you identify areas where you might need to make changes to move into compliance You will be asked to keep this self assessment on file, with evidence to support your responses, until December 31, 2017 Additional training on how to complete this self assessment will be provided in August 2016

IDAPA This subsection specifies that any new HCBS providers will be expected to fully comply with the HCBS qualities as a condition of becoming a Medicaid provider In addition, the Department will begin enforcement of quality assurance compliance with the setting requirements on January 1, This means that the Department will not request corrective action for compliance issues identified between now and January 1. This does not mean that providers do not have to comply with the requirements until January 1.

Compliance Timeline 35 Rules go into effect Enforcement of HCBS begins Idaho’s formal assessment of HCBS settings begins Transition of participants to HCBS-compliant settings if non- compliant settings are identified. Full compliance established. Ongoing monitoring of HCBS compliance continues. July 1, 2016January 1, 2017January 1, 2018March, 2019

Upcoming Training Opportunities 36 Date Topic May :00PM Mountain Time (12-1:00PM Pacific Time) Repeat of All Settings Rules Overview (Teleconference only) May :00PM Mountain Time (2-3:00PM Pacific Time) Repeat of Residential Settings Rules Overview (Teleconference Only) July :00PM Mountain Time (12-1:00PM Pacific Time) Provider Toolkit Overview (WebEx) August 2 1-2:00PM Mountain Time (12-1:00PM Pacific Time) Provider Toolkit Overview (Teleconference Only)

Keep in Touch! 37 Additional training will be offered over the next several months. You can stay informed about training opportunities, educational materials, and other HCBS- related information by: Visiting the HCBS webpage at: ing the program at: to be added to our distribution

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